Ectopic Pregnancy

Dr S.A. Uzoigwe.
Definition:
Implantation of a fertilized ovum outside
the endometrial cavity, or in any tissue
other than the endometrium
Importance:
Life threatening surgical emergencies when it is
ruptured
Maternal mortality (1990-2001) period of 12 yrs.
1225 autopsies (38=3.1% )
Maternal morbidity
Effect on future fertility
– (½ of them will unlikely conceive )
– (⅓ of them will deliver live born infants)
– (25%will suffer repeat ectopic )
Economic implication for the patient
Almost fatal to the embryo
Incidence:
Varies considerably in different parts of the world.
Rising.
In UPTH (over 8 years review by Dr. Uzoigwe\Prof.
John)=1 in 57 or 1.8%
Accounted for 9.0% of gynaecological patients.
Ibadan:2.7%,Benin:2.3%,Jos:1.6%
1:43- 1:200 live births (U.S.A).
West Indies 1:28(Douglas)

Reason for rising incidence

Adequate treatment for P.I.D. which in the past rendered
women sterile
IUCD use
Increase in surgical procedures for tubal disease
Improved diagnostic technique.
2 types of ectopic pregnancy
Ruptured
Unruptured
Location (sites) of implantation
Fallopian tube (96%).
– Ampullary region more common in (distal ⅔)
– Isthmus,
– Fimbriae,
– Interstitial(2%)
Cervical, abdominal and ovarian 2%
Heterotopic: combination of intrauterine and extrauterine
gestation 1:30,000 (1:4000-15,000). Common in assisted
reproduction (pregnancies) techniques 1:100.
Bilateral ectopic( Incidence unknown).
Broad ligament.
(Which sides of the tube is very common= RT)
Aetiology
Unknown.
Risk factors ( impair the migration of the fertilized ovum to the
uterus or those that affect the tubal motility).
P.I.D, contribute to 50% of all cases.
Tubal endometriosis (rare).
Tubal surgery (previous), tubo-tubal fistula .
Intrauterine devices( IUCD).
Transmigration (migration of the ovum).
Previous Hx of ectopic pregnancy.
Hx of Infertility.
Intrauterine diethylstilbestrol exposure.
Conception following IVF-ET.
G.I.F.T.
Z.I.F.T.
Previous abdominal surgery
Induction of ovulation following menopause gonadotrophins.
Progestogen contraception.
Induction of ovulation with menopausal gonadotrophin
Natural course of ectopic gestation.

Tubal abortion with the formation of

haematocele.
Rupture into the peritoneal cavity.
Resorption.
Rupture into the broad ligament.
Abdominal pregnancy.
Diagnosis.
Symptoms
Amenorrhoea (89%). May occur before the patient
misses her period especially if it is in the isthmus).

Pain (94%).Irritation of the peritoneum, distension of the

gravid tube. Shoulder tip pain if blood tracks to the
diaphragm and stimulates the phrenic nerve. Lower
abdominal pain.

Irregular vaginal bleeding (80%). (Effect of E2 withdrawal

occurs after death of the ovum. Spotting. Decidua grows
abundantly, it can be expelled as decidual cast).
Signs.
Evidence of blood loss
– Anaemia
– shock (Hypovolaemia)
– collapse (Hypotension)
– distension of the abdomen (shifting dullness)
-Abdominal tenderness, guarding, rebound
tenderness.
Fluid thrill +ve
Shifting dullness.
VE: - Cx-al excitation tenderness.
– Bleeding = brownish.
– Fornices will be tender and bulging occasionally
Other methods for making diagnosis.

Culdocentensis / cul-de-sac- puncture

USS imaging especially transvaginal using
vaginal probe.
B Submit of hCG (RIA) (abnormal
progression of BhCG level) = In normal
pregnancy levels double every 2.4 days
with a predictable slope of increase.
Absence of this slope is abnormal (ectopic
pregnancy).
Laparoscopy
Differential Diagnosis
Chronic PID
Acute PID
Acute appendicitis
Chronic appendicitis
Spontaneous or induced abortion
Threatening abortion
Incomplete abortion
Torsion of an ovarian cyst
Rupture of an ovarian cyst.
TREATMENT

Surgical
Medical
SURGICAL
I.V.Line. D/S. Use a wide-bore cannula
Aspirate blood for grouping and cross-matching-1hr crossmatch.Uncross-
matched O negative blood
Get to theatre as quickly as possible
Inform anaesthetist
Open and arrest the bleeding.TECHNIQUE. The scrub nurse can double as
an assistant.

Incision to make: Preferably midline vertical

LAWSON TAIT of Birminghan who performed the first successful surgery for
ectopic in 1880; MAKE AT ONCE AT THE SOURCE OF
HAEMORRAGE,TIE IT ,THEN OTHER THINGS CAN BE DONE AT
LEISURE.
At surgery inspect both ovaries and Fallopian tubes
– Partial salpingectomy
– TotaL Salpingectomy
– Salpigostomy
AUTOTRANSFUSION.STEPS:duration of haemoperitoneum < 24hrs.

Laparoscopy.RU486(MIFIPRISTONE) Iinjected to abortit from the fimbrial

end.
 Steps in autotransfusion
Place 8 layers of sterile gauze over a
sterile measuring jar to filter clots,fat
globules.
Use kidney dish or gallipot to remove free
unclotted blood from the peritoneal cavity.
Tge filtered blood is transferred into citratd
bottle(s).
Transfuse back through blood giving set.
14
MEDICAL:

Systemic methotrexate,
Actinomycin D
Local administration of KCL, methotrexate,
mifipristone, prostanglandin E2 into the
gestation.
 Closure of the abdomen
-there is no need closing both visceral and
parietal peritoneum.
-use continuous O or no. 1 polyglycolic or nylon
suture for the rectus sheet.
-if not more than 2cm,the subcutaneous layer
may be left. If it becomes necessary,interrupted
O plain or 2/0 chromic catgut may be used.
Drainage is not necessary unless in chronic
ectopic pregnancy.

18 16
 Skin closure
O or 2/0 silk or nylon
Postoperative Care
-blood transfusion if necessary
-i.v. fluid until bowel sound is present
-analgesia (analgin or pentazocine)
-broad spectrum antibiotics(ampicillin or ampiclox i.v.)
-Commence orally as soon as the i.v. line is discontinued
-Sit the patient out as soon the condition permits ,usually
on the second day of the operation.
-discharge home on the 5th or 6th day
-give 2 weeks appointment to the outpatient clinic, there
after 4 weeks.
Discharge
Counselling
Prognosis
Family planning method
Correct anaemia with ferrous sulphate
Follow up visit.